CLIENT DETAILS

First Name *

Last Name *

Phone *

Email *

Date of birth *

Emergency Contact Name & Number: *

TREATMENT INFORMATION

Treatment Requested *

PMU Brows

PMU Lips

PMU Eyeliner

Date of appointment: *

MEDICAL HISTORY

Please select Yes or No for each question below. If you answer Yes to any question, please provide details in the box at the end of this section.

Are you pregnant or breastfeeding? *

Yes

Do you have any active skin conditions (e.g. eczema, psoriasis, rosacea) in or near the treatment area? *

Yes

Do you have a history of cold sores or fever blisters (HSV-1)? *

Yes

Do you have any allergies to anaesthetic creams, topical products, or latex? *

Yes

Are you taking blood-thinning medication (e.g. aspirin, warfarin, ibuprofen)? *

Yes

Are you currently taking Accutane (isotretinoin) or have you used it in the past 12 months? *

Yes

Do you have diabetes or any condition affecting healing? *

Yes

Do you have a history of keloid scarring or hypertrophic scarring? *

Yes

Do you have any autoimmune disorders or conditions affecting the immune system? *

Yes

Are you currently undergoing chemotherapy or radiation treatment? *

Yes

Have you had Botox or dermal fillers in the treatment area within the past 4 weeks? *

Yes

Have you had laser treatment, chemical peels, or microneedling in the area within the past 4 weeks? *

Yes

Do you have a pacemaker or other electronic implanted device? *

Yes

Have you previously had a reaction to a tattoo or PMU procedure? *

Yes

Are you on Roaccutane or vitamin A supplements? *

Yes

If you answered Yes to any of the above, please give details:

SKIN AND LIFESTYLE

Do you use retinol, AHAs, or active skincare products on or near the treatment area? *

Yes

Do you use sunbeds or have significant sun exposure? *

Yes

Do you have any existing tattoos or PMU in the treatment area? *

Yes

Current skincare products used:

CONSENT AND DECLARATION

By signing below, I confirm that:

All information provided on this form is accurate and complete to the best of my knowledge.

I understand that withholding information may affect the safety or outcome of my treatment.

I have been given the opportunity to ask questions and am satisfied with the information provided.

I understand that results vary and there are no guarantees regarding the final outcome.

I understand that a patch test may be required and that I should follow all aftercare instructions provided.

I consent to photographs being taken for the purposes of my client record (these will not be shared without my consent).

I agree to inform my artist of any changes to my health or medication between sessions.

Client signature: *

Clear

Please sign the form in the box above